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FROM THE FIELD

Applying Lessons Learned In Communities To Programs And Policies At The Federal Level

Abstract

 
As solutions to the problems of the uninsured are debated, there are lessons to be learned from community-based initiatives. Such efforts can provide information on different models as well as key political lessons. Defining the specific role that community efforts play is also critical. Actively involving community stakeholders of such community initiatives in health care policy debates will result in more workable policies.

Lesson 1: informing the federal health policy debate. Community efforts can provide key information to inform the federal health policy debate. As a former federal official who has worked directly in the community to put innovative programs in place, I fully appreciate this role of community programs. When one works in the community, one focuses on answering different, more operational, questions than those that get asked at the federal level. For example, questions are asked about how to make a program truly accessible for families through the enrollment process and how to make the delivery system support the people it is intended to serve by improving provider participation. An exploration of community-based efforts illustrates why we should not dismiss community-based initiatives because of their presumed lack of broader applicability or replicability. In fact, as long as the limitations are clearly stated, information about community-based programs can provide valuable insights at higher levels of involvement.

Community-based approaches act as a reality check of what is doable and practical: They can provide an actual model of what works; they help identify promising practices in key areas; and they can provide lessons about how to address political issues. For example, when the State Children’s Health Insurance Program (SCHIP) was being developed in Washington, D.C., three model programs in Florida, Pennsylvania, and New York were identified and studied; ultimately, these programs were treated in a special way under the new law. These "model community programs" provided a practical example of what was possible in the debate on expanding children’s health care coverage.

Later, when SCHIP was being implemented by the U.S. Department of Health and Human Services (HHS), a network of SCHIP directors was available through the Web to share experiences on what worked and what did not work, ultimately identifying promising practices in real time. For example, states developed innovative ways to streamline the eligibility process, identifying the best mechanisms, such as passive renewal, by which states presume that a family is eligible unless a person’s circumstances change. Similarly, at Nemours Health and Prevention Services, we learned quickly that a "collaborative learning" model is the best approach for reaching key community organizations through group learning and sharing of ideas. We have used the collaborative learning model to share promising practices in the area of healthy eating and physical activity to address overweight among children.

A key lesson from community-based initiatives is that policy cannot be developed in isolation from the political environment. The practical reality is that at the community level, working collaboratively is a necessity. After successfully developing a new system to address rate setting for the Maryland Medicaid managed care plan, we learned to not be complacent, because there will always be unfinished business. It was important to sustain political alliances and keep coalitions functioning over time, to ensure support for the program. We worked very closely with managed care plans, always negotiating in good faith, and with the legislature.

In preparation for more focused attention on the problems of the uninsured, it would make sense to comprehensively review the range of current and past community-based efforts to identify what worked and what did not, and more importantly, the reasons for success or failure.²

Lesson 2: appropriate flexibility. One cannot read the four papers dealing with community initiatives without asking, What is the proper division of roles among the federal, state, and community levels in efforts to expand health care, particularly at the community level?³ Key issues are where there should be flexibility, and where there should be minimum standards.

Just as with politics, all health care is local, and different strategies might be more or less successful for different communities. This highlights a key issue for expanding coverage as stated above: What areas should not vary by community and state, and what areas should have flexibility? This tension between the need to have consistency across the country and the need to allow for flexibility is commonly raised for joint federal-state programs such as Medicaid but also applies to federal programs such as Medicare. In both cases, there has been flexibility in the delivery of care at the community level. With respect to the community role, two of the papers in the four-paper package make the point that communities have more ability to make an impact in areas related to the delivery of care.⁴ As we consider federal approaches to coverage, we must allow for differences at the local level in the delivery of care and not micromanage the health care delivery system. Successful programs such as the ones in Hillsborough County, Florida, and Muskegon, Michigan, have inspired communities across the country and can provide great insight into accomplishing coverage.⁵ However, this does not mean that every community should be required to have similar programs.

Lesson 3: community involvement in health policy debates. When one is on the ground level working in a community, it is natural and essential to directly involve community stakeholders such as key providers, consumers, and families in policy development through focus groups or other forums of discussion. One learns that information from families and practicing providers about the practical workability of policies contributes to sound policy making. For example, one important lesson from SCHIP is that eligibility itself, established by the federal and state government, is only one aspect of making sure that coverage for children is a reality. The community played a key role in getting the word out about SCHIP and ensuring successful enrollment. States asked various nonparticipants why they did not enroll and what would make the enrollment process easier. States then worked to make changes in the programs to make eligibility determinations easier for families.

Based on my experience at the federal, state, and community levels, the more distance one has from the community, the less one actively involves community stakeholders in the development of policies and programs. As a part of the federal policy development process for the next round of discussions on how to solve the problems of the uninsured, it would make sense to bring together federal and state health care experts and community leaders, including practicing providers and consumers, with experience in developing and implementing community programs to work together to develop solutions. One key topic for discussion would be how to work together to identify where there should be state or local flexibility and where there should be federal standards for consistency. In addition, it would be prudent to vet any proposal with community providers and families to troubleshoot and refine proposals. If more time were spent in soliciting community input, the system would be more user-friendly for both families and providers.

AS NATIONAL ATTENTION turns once again to the plight of the uninsured, policymakers would benefit from focusing on community-based initiatives. This should include (1) reviewing and researching current community programs for programmatic and political lessons learned; (2) defining the role of the community as compared with the federal and state roles, including allowing local flexibility to deliver care; and (3) bringing families, practicing providers, and other community stakeholders who have been a part of such efforts together with the experts to provide input to and develop policy. It’s the details that make passing major health reform initiatives nationally difficult. We must not overlook the lessons that can be learned from community initiatives.

Editor's Notes

 
Debbie I. Chang (dchang{at}nemours.org) is senior vice president of the Nemours Foundation and executive director of Nemours Division on Health and Prevention Services, in Newark, Delaware.

The opinions expressed are those of the author and do not necessarily reflect those of the Nemours Foundation. The author thanks Linda Boltman and Bob Colnes for their quick research assistance.

NOTES

Top NOTES

 

1. L.D. Brown and B. Stevens, "Charge of the Right Brigade? Communities, Coverage, and Care for the Uninsured," Health Affairs 25 (2006): w150–w161 (published online 11 April 2006; 10.1377/hlthaff.25.w150).
2. D. Andrulis and M. Gusmano, Community Initiatives for the Uninsured: How Far Can Innovative Partnerships Take Us? (New York: New York Academy of Medicine, August 2000); and S. Silow-Carroll, T. Alteras, and H. Sacks, Community-based Health Coverage Programs: Models and Lessons, A Series of Community Voices Publications, February 2004, http://www.communityvoices.org/Uploads/CommunityBasedCoverageFinal_00108_00044.pdf (accessed 3 April 2006).
3. Brown and Stevens, "Charge of the Right Brigade?"; L.D. Brown, "Impermanent Politics: The Hillsborough County Health Care Plan and Community Innovation for the Uninsured," Health Affairs 25 (2006): w162–w172 (published online 11 April 2006; 10.1377/hlthaff.25.w162)[Abstract/Free Full Text]; E.F. Taylor, P. Cunningham, and K. McKenzie, "Community Approaches to Providing Care for the Uninsured," Health Affairs 25 (2006): w173–w182 (published online 11 April 2006; 10.1377/hlthaff .25.w173)[Abstract/Free Full Text]; and E.F. Taylor et al., "Who Enrolls in Community-based Programs for the Uninsured, and Why Do They Stay?" Health Affairs 25 (2006): w183–w191 (published online 11 April 2006; 10.1377/hlthaff.25.w183).[Abstract/Free Full Text]
4. Brown and Stevens, "Charge of the Right Brigade?"; and Taylor et al.,, "Community Approaches."
5. Brown, "Impermanent Politics"; and P. Fronstin and J. Lee, "A Community Expands Access to Health Care: The Case of Access Health in Michigan," Health Affairs 24, no. 3 (2005): 858–863.[Abstract/Free Full Text]

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